EH 10.02-02 Beer & Wine Application Page 1 of 3 Rev. 01/2018 Beer and Wine License Application 1. Application Type New Transfer [ Applicant Location] Change Current Application [ Floor Plan License Types (See #2)] Business Opening/Transfer Date: 2. License Type and Fees See Instruction Sheet for Fees Beer $50.00 Wine by the bottle $100.00 Wine by the Glass $100.00 Keg Beer to Go $20.00 Growlers $0.00 On-Premises Consumption $0.00 Restaurant $0.00 Total Fees: 3. Applicant Information A. Applicant Name: (Individual, Corporation, LLC, Partnership or other business entity) Business Phone No.: Business Physical Address: City: County: Zip: Mailing Address: (Include City, State, Zip) Alternative Phone No.: E-Mail Address: Former Business Name (Transfers Only): B. State Tax Commission C. Business Bank Name and Address (Branch): Person(s) Authorized to Sign on Account: Title: 4. List sole proprietor(s) or all partners, corporate officers, directors, ten primary stockholders, LLC/LLP members/partners of the applicant. Attach a separate sheet of paper following the format below. Name: Address: Title: SSN: Date of Birth: Idaho A. Sole Proprietor(s): by following the format below (fingerprints are required ) or provide a Separate Property Agreement] Name: Address: Title: SSN: Date of Birth: Idaho Resident: (Y/N) B. Has Applicant or anyone listed on #4 ever had an alcohol license suspended, denied or revoked? No Yes (If yes, attach explanation) C. Has Applicant or anyone listed on #4 ever been convicted of any felony, any alcohol-related misdemeanor or facing any pending criminal charges? No Yes (If yes, attach explanation) Idaho State Police Alcohol Beverage Control Bureau 700 S. Stratford Dr. Ste 115 Meridian, ID 83642 Phone (208) 884 - 7060 Fax (208) 884 - 7096 www.isp.idaho.gov/abc Premises File Number: License Number: See Instruction Sheet American LegalNet, Inc. www.FormsWorkFlow.com EH 10.02-02 Beer & Wine Application Page 2 of 3 Rev. 01/2018 5. Has Applicant or anyone listed on #4 ever held any interest in any other business licensed for the sale of alcoholic beverages? No Yes [If yes, attach explanation - Include Premises Number(s)] 6. including silent partners, private financial loans, etc.? No Yes [If yes, complete explanation below] Name: Phone Number: (lender/partner name) Address: Ownership interest: (amount/percentage) 7. List the owner of the building where the premises is located: (Include a copy of the building lease to the Applicant OR a warranty deed ) 8. Premises Diagram/Floor Plan No architectural blue prints On paper no larger than 8 275 x 11 Attach a sketch showing the entire area proposed to be licensed to sell, serve, dispense, or store alcoholic beverages, including patios, decks, etc. Diagram must show all entrances, exits, offices, restrooms, kitchen facilities (if applicable), bar(s), bar backs, liquor cabinets, tables, refrigeration units, partitions, etc. and where license will be prominently displayed. 9. Affirmation: The applicant(s) hereby swears or affirms under oath that the applicant is the bona fide owner of the business which is applying for this license and will be engaged in the sale or dispensing of liquor by the drink, beer and/or wine by the bottle and/or glass. The applicant(s) hereby affirms that the applicant and/or each person indicated on this application or attachments thereto is/are eligible and has none of the disqualifications for a license as provided by Title 23, Chapter 9, 10, 11, 12, 13 and 14, Idaho Code, IDAPA 11.05.01 or any amendments thereto. An application for and acceptance of a license by the applicant(s) shall constitute consent to, and be authority for, entry ept, , check and investigations aforesaid with relation to said licensee or any other licensee. The application shall also constitute consent given to the Director, his agents, to said business, and to make the inventory, check and investigations aforesaid with relation to the said licensee or any other licensee. The application shall also constitute consent given to the Director or his authorized agents to view, copy or investigate any documents, including state and federal income and sales tax returns and any documents, associated with the person or business that are exercising the privilege of the license, as per Idaho Code sections 23-907, 23-1006 and 23-1314 and IDAPA 11.05.01. Applicant(s) hereby acknowledges that falsifying this document or submitting any false documents for record can result in a felony conviction under Idaho Code sections 23-905 or 18-3203. Applicant(s) further acknowledges that they and/or each person indicated on this application or attachments understand that state law controlling alcohol beverage licensing is found at Title 23, Idaho Code ( http://legislature.idaho.gov/idstat/Title23/T23.htm ) and the Alcohol Beverage Control administrative rules, IDAPA 11.05.01 ( http://adminrules.idaho.gov/rules/current/11/0501.pdf ), and that any violation of these laws or rules can result in criminal and/or administrative sanctions, and up to and including license revocation. Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedure for obtaining a change, correction, or updating an FBI identification record are set forth in Title 28, CFR, 16.34. **See page 3 for required signature page American LegalNet, Inc. www.FormsWorkFlow.com EH 10.02-02 Beer & Wine Application Page 3 of 3 Rev. 01/2018 10. Signature Attestation: I/we, the applicant(s) of this license, have read all of the above and declare under penalty of perjury that the information that I/we have provided is true and correct to the best of my/our knowledge. I/we, the applicant(s) of this license, acknowledge and understand Idaho Code Title 23 and IDAPA that regulate licenses provided by the Idaho liquor act and do hereby agree to operate the licensed premises in conformity with these statutes and regulations. Title Date Subscribed and sworn to before me this day of , 20. (NOTARY SEAL) Residing At: My Commission Expires: American LegalNet, Inc. www.FormsWorkFlow.com Rev. 08 /2018 ALCOHOL BEVERAGE CONTROL BUREAU 700 S. Stratford Dr. Ste 115 Meridian, ID 83642 (208) 884 - 7060 E - Mail: abc @isp.idaho.gov INSTRUCTIONS FOR BEER AND WINE ALCOHOL BEVERAGE LICENSES For information regarding ABC licensing, laws, rules and frequently asked questions visit our website: www.isp.idaho.gov/abc . All blanks must be completed . Follow all instructions printed on the application. An y incomplete application will be returned to applicant. Alcohol Beverage Control Bureau has 90 days to process and investigate any application received. Fees: All fees must accompany the application and supporting documents. Do not mail cash. Credit Card Authorization form is available on our website. Make all checks payable to : State of Idaho . NOTE: If your funds are deposited, they will be deposited in accordance with Idaho Code 59 - 1014 . The depositing of your licensing fees does not guarante e the issuance of a license. Mailing: Express mail envelopes for return service will be used only when provided by the applicant. The applicant must be listed as both the sender and receiver with the postage pre - paid. Completing the Application: Forms must be legible (printed or typed). Applications must be signed and notarized. 1. Application Type: Mark the appropriate box indicating the re ason for the application (e.g . , new applications , transfer, change current ). For transfers, mark the appropria te box for the type of transfer. a. schedule the premises inspection, which is required to be completed before a license can be issued. If your premise is currently under construction , use the date when construction will be 95% complete as the opening date. b. anticipated transfer date on i. Complete the box in the upper right - hand corner with the requested information from the license being transferred . c. are changing. d. A restaurant is: A full service restaurant with kitchen facili